Citizens Correctional Academy

Understanding Corrections and Enhancing Community Safety

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* 1. Full Name

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* 2. Date of Birth

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* 3. Home Address

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* 4. Driver's License Number

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* 5. Occupation

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* 6. Organization Name

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* 7. Mobile Phone Number

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* 8. E-mail address (used for communication and class cancellations)

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* 9. Where did you hear about the Citizens Correctional Academy?

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* 10. Briefly explain your interest in attending the Citizens Correctional Academy

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* 11. I hereby certify that the information contained in this application is true and complete to the best of my knowledge. By signing below, I hereby authorize the State of Rhode Island and the RI Department of Corrections to make any investigation of my personal history deemed necessary for consideration to attend the Citizens Correctional Academy.

As consideration for allowing me to participate in this program, I hereby waive any claim whatsoever by myself, my heirs and assigns, against the State of Rhode Island and the RI Department of Corrections, which may accrue as a result of my participating in this Citizens Correctional Academy.

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